Shoulder Injuries in Ice Hockey*

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1 /88/ $02.00/0 THE JOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyright Q 1988 by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association Shoulder Injuries in Ice Hockey* ROBERT C. FINKE, PT, ATC,+ SUSAN GOODWIN GERBERICH, PhD? MARCIA MADDEN, MPH: SUSAN FUNK, MPH Candidate," KEVIN MURRAY, MS,QAMES D. PRIEST, MD," GORDON M. AAMOTH, MDu A study of shoulder injuries incurred by high school ice hockey players was conducted for the and competitive seasons. Data from 480 players (73%), who competed on 12 teams within a 30 mile radius, were included in the analysis. Among these players, shoulder injuries accounted for a rate of 9.4 injuries per 100 players; separation of the acromioclavicular joint was the most common injury. Although 39% of the reported injuries were of mild severity, 44% were moderate in severity, and 18% were major in severity; moreover, 59% of the injured players reported residual persistent symptoms. Of the total injuries, 88% occurred in games or under game-type conditions. The greatest proportion of injuries occurred to players engaged in play in the forward position while in the offensive zone. Over 54% of the injuries were caused by contact with the boards surrounding the ice surface and, reportedly, 43% of the injuries were associated with illegal activities. Based on the study findings, strategies for injury prevention include the following: consideration of techniques of coaching and of play; enforcement of the current rules to decrease the number of injuries related to illegal activities; research relevant to board design and materials to determine if a more yielding barrier can be placed around the playing surface; and utilization of the latest equipment, incorporating unique design and materials, that facilitates dissipation of forces. In addition, there is a need for further comprehensive research efforts relevant to ice hockey injuries that can enable the identification of other risk factors so that preven#on and control of injuries can be managed more readily. The sport of ice hockey has enjoyed rapid letes treated in emergency rooms for injuries inexpansion over the last two decades. Between curred while participating in ice hockey.i4 In an 1965 and 1985 a 4-fold increase in amateur earlier study, SutherlandI3 reported injuries that hockey team registrations was documented in the occurred at four levels of hockey participation: United states.' In addition, there are approxi- youth, high school, college, and professional; remately 24,000 participants at the high school level sults from this study indicated a concomitant inthroughout the United States; 20% of these play- crease in the incidence of injury with an increase ers participate in the state of Minnesota.' in the level of skill and intensity of activity. This In there were an estimated ath- trend was further supported by findings recorded from a 2-year study of hockey injuriesby Daffne? Financial support for this study was provided by: the Hubbard Foun- and a Of clavicle injuries dation, St. Paul, MN; lnstitute for Athletic Medicine, Fairview Community fray.'' Hospitals, Minneapolis, MN; lnstitute for Athletic Medicine of John C. Lincoln Hospital. Phoenix, AZ; The Mendon Schutt Foundation. Min- Injuries the in ice are neapolis; Minnesota State High School League, Anoka, MN; University uncommon. Yet, few studies relevant to this probof Minnesota Computer Center; multiple private donations. t Coordinator of Sports Medicine Services, Braemar Sports Medicine lem have been Through a 5-year study Center Washington Avenue South, Edina, MN of injuries at the collegiate level, Reilly" reported $Assistant Professor, School of Public Health, University of Minnesota; Director of Research, Institute for Athletic Medicine, Fairview Commu- the shoulder to be a primary injury location. Simnity Hospitals. Minneapolis. ilarly, Hovelius5 and Norfray'' reported a high 5 Nursing Education Instructor, United Hospitals, 333 North Smith Avenue, st. Paul, MN incidence of injury to the shoulder girdle. The 11 Senior Health Care Specialist, Northwestern National Life Insurance presence of hard, unyielding surfaces such as the Company, Minneapolis. II Biomechanical Engineering, University of Minnesota, Minneapolis. ice, goal posts, and the boards surrounding the # Orthopaedic Surgeon, Orthopaedic Consultants, P.A., Suite 701, ice can result in significant forces being transmitted to the body during game Or practice th Avenue South and Clinical Associate Professor, Department of Orthopaedic Surgery, University of Minnesota, Minneapolis.

2 JOSPT August 1988 SHOULDER INJURIES IN HOCKEY 55 activities. In addition, the force of contact between two players moving at full speed can result in musculoskeletal or other more severe injuries. Finally, the combination of forces generated by a player colliding with an opponent which results in a subsequent collision into an unyielding surface presents yet another potential for injury. Shoulder injuries may result from either direct or indirect forces.= The direct forces occur when the player strikes another object such as boards, goals, ice, or another player. Indirect forces may occur when a player falls to the ice or into the boards or goals with the arm outstretched; the force is then transmitted along the arm to the shoulder girdle. Reilly" reported player contact as the major source of injury in his study (43.3%); the percentage of injuries resulting from contact with the boards, the goals, or the ice surface was very small in comparison. Norfraylo found that direct trauma was the predominant cause of acromioclavicular injuries while indirect forces resulted in fracture to the clavicle. Based on concerns identified by Minnesota interscholastic hockey coaches, this study was undertaken to determine the magnitude of the problem of shoulder injuries among high school hockey players and to identify variables associated with these injuries. MATERIALS AND METHODS This study was conducted as a part of a comprehensive epidemiological study of high school injuries during and hockey season^.^ The comprehensive study was a retrospective study using a questionnaire format. A total of 12 high school interscholastic teams located within a 30 mile radius of the MinneapolisSt. Paul Metropolitan area were selected for participation: these selections included public, private, urban, and suburban teams based on the general composition of the geographical area. The populations accounted for 333 players during the season and 327 players during the season. Data were obtained from 75% of the first year participants and 70% of the second year participants. An injury was defined as one that kept the athlete from participating in regular game or practice activity following the day of onset. Severity of injury was classified as follows: 1) minor, the athlete returned to active participation or play within 1 week; 2) moderate, the athlete returned to active participation or play within 1-3 weeks; 3) major, the athlete was out of participation or play for more than 3 weeks; 4) severe, the athlete sustained a permanent, disabling injury. Shoulder injuries included any injury to the upper extremity at a level ranging between the elbow and the shoulder girdle, including the attachment of the clavicle to the sternum. The decision not to participate was not consistently made by one individual but varied according to the severity of the injury. Injuries of moderate, major, or severe nature were usually evaluated by a physician who participated in the decision to return to activity. At the conclusion of each hockey season an informational meeting was conducted for varsity team members. At these meetings pretested questionnaires were distributed by the investigators and instructions were provided to all of the players. Information regarding injuries incurred as a result of participation in the respective hockey seasons was requested. Additional data were collected including age and experience of the players, the activity associated with the injury, equipment worn, position played, activity at the time of injury, and any residual symptoms. According to federal guidelines on the use of human subjects in research, informed consent was provided to the players; a parent was requested to read the player's questionnaire and a cover letter, and to sign the informed consent. Questionnaires were returned directly to the investigators to ensure confidentiality. To facilitate returns, a total of four mailings were used. An additional follow-up study was conducted to validate the shoulder injuries identified by the players. This follow-up consisted of letters to the physicians, personal contacts with the players, and personal contact with physicians who treated the players. All data received from the responding players were verified and entered into the computer. Descriptive statistics were primarily employed, utilizing the Statistical Package for the Social Science~.'.~ RESULTS Data were obtained from a total of 480 players (73%) who participated on the high school hockey teams during the and seasons. Among these players, 44 players (9.2%) reported 45 shoulder injuries (Table 1). These injuries accounted for 16% of the total injuries during the first year of study and 12% of the injuries during the second year of study. In addi-

3 56 FlNKE ET AL JOSPT Vol. 10, No. 2 Type of Injury TABLE 1 Shoulder injuries incurred among high school hockey players Total Number YO Number O/O Number O/O Acromioclavicular joint injuries Sternoclavicular joint injuries Fractures Muscles strains Contusions Glenohumeral subluxations Lacerations Pinched nerve Other Total Injury rate participants participants participants tion, recurrent injuries accounted for 14 and 13% of the shoulder injuries reported during seasons one and two, respectively. A recurrent injury was defined as the same injury incurred by the same shoulder following return to full competition. lnformation relating to severity of injury was identified in 39 cases (Table 2). Of these, 39% were of mild severity and restricted the players' activities for less than 1 week; 44% were identified as moderate in severity and restricted the players from activity for 1-3 weeks. In addition, 18% of the shoulder injuries were of major severity and restricted activity for more than 3 weeks. Surgical intervention was required in two cases; one of these resulted in disabling residual symptoms. Analysis of the activity a player was involved in when the injury occurred revealed that 63% occurred during game activity, with an additional 25% occurring during competition at practice, including scrimmages. Therefore, seven of eight injuries occurred under competitive conditions. The period of the game or practice was not associated with injury occurrence, however. The most commonly identified position/activity at the time of injury was a forward playing offense (Table TABLE 2 Severity of shoulder injuries incurred by high school hockey players, and seasons Restricted Number % Adjusted from Activitv %' Less than 1 week weeks More than 3 weeks No Information Total ). This accounted for 55% of the shoulder injuries. Lower percentages were associated with the remaining four position/activity categories. Of the total shoulder injuries, 57% were associated with legal activities, while illegal activities were associated with 43% of the injuries. Of these, 31% were associated with illegal body checks, such as checking from behind, charging, and boarding. The remaining injuries were related to illegal stick activity (i.e., tripping, slashing). Players were asked to identify what objects they struck that facilitated the injury-causing force to their shoulders; 54% identified the boards as the primary object, followed by 30% who identified other players as the object struck (Table 4). Some players reported that the boards were the source of force secondary to contact with other players. Of the 39 players who provided information regarding persistent residual symptoms at the end of the season, 59% reported associated discomfort (Table 5). The majority (41%) reported mild discomfort while only one player reported great discomfort. TABLE 3 Positionlactivity at time of injury Forward on offense Forward and defense Defenseman on offense Defenseman on defense Goalie No information Total * Includes missing data. * Includes missing data. Number of Players Adjusted %*

4 JOSPT August 1988 SHOULDER INJURIES IN HOCKEY 57 Source of Injury Boards Player Stick Ice Puck No contact No information Total * Includes missing data. TABLE 4 Source of injury-causing force Number % Adjusted %* TABLE 5 Hockey players with postinjury physical symptoms Residual Symptoms Number % Mild discomfort Some of the time All of the time Moderate discomfort Some of the time All of the time Great discomfort Some of the time All of the time No discomfort No information Total Includes missing data. Analyses to determine potential differences between players who incurred a shoulder injury and those who did not revealed no significant differences in the height of the players, playing experience in years, or performance rating (i.e., key or regular player, special team, or tryout player). However, players 16 to 18 years of age, and those who weighed 160 Ibs or more, had a risk at least two times that of the players 14 or 15 years of age and those who weighed less than 160 Ibs (p < 0.05). DISCUSSION Results of the present study confirm findings from previous studies, identifying the shoulder structure as a potential area for significant injury in the sport of ice hockey.58103" This is also consistent with anecdotal reports made to the investigators by scholastic coaches. Shoulder separations were identified as the most prevalent injury during the two-season study: 38% of the injuries were separations at the acromioclavicular joint. Similar to the change in rates for all types of injuries between the first and second study year %^ was an apparent decrease in the rate of shoulder separations from 11.6 to 7.0 per 100 participants. In this study, it was found that players 16 to 18 years of age and those who weighed 160 Ibs or more had a risk of shoulder injury two times that of the younger and lighter weight players. This finding is similar to that identified in a previous major epidemiologic football study of 3000 players and is, undoubtedly, associated with the differences in the magnitude of the forces generated.4f12 Further study of all types of hockey injuries and shoulder injuries, in particular, is essential. However, the following are offered for consideration. A decrease in injuries found in one of the teams studied which had made changes in equipment and coaching techniques between years one and two of the study suggests a potential value in these methods for decreasing injuries. Newer types of protective equipment for the shoulder have been developed which take into account the need for proper fit and adequate resistance to forces. Yet, a major problem in the manufacture of shoulder equipment has been the inability to stabilize the equipment during rigorous activity. This presents a particular problem for the acromioclavicular joint which is subject to a high incidence of injuries. The results of this study do not appear to indicate that shoulder injuries can be prevented by preparticipation screening programs. However, such screening might prevent a recurrence of some of the shoulder injuries identified. In this study, the most common source of shoulder injuries was contact with the boards. Although this finding varied from the data previously reported by Reilly, who indicated player contact as the most common source of injury, the results were in agreement with those reported by Norfray, who indicated that direct force was the most common mechanism.lo~" It should be noted that there exists a possibility of a difference in classification among the various studies, in that an injury classified as a player-related injury may in fact have been an injury caused by contact with the boards following contact with an opposing player. Proper coaching in the fundamentals of hockey participation may also be a significant factor in injury prevention. Instructing players in specific techniques for receiving body checks may facilitate diffusion of the impact of the forces. The importance of preparation of the coach in injury

5 58 FlNKE ET AL JOSPT Vol. 10. No. 2 prevention and care has been documented through epidemiological studies of football injuries and needs to be explored further with regard to hockey inj~ries.~ Moreover, since one-third of the injuries identified in this study were, reportedly, the result of illegal activity, closer supervision and instruction by coaches and enforcement of rules by officials are also essential to injury prevention. Finally, the unyielding board surfaces were determined to be a major source of impact forces associated with injuries identified both in the comprehensive study as well as within this investigation of shoulder injuries. Changing the composition of the boards to facilitate energy absorption should be investigated in an attempt to reduce the overall rate of injuries in ice hockey. A similar problem related to the stationary hockey goal has been addressed and improved significantly. The goal posts currently used are designed so that they will break away from their fixed position when struck. This reduces the forces transmitted when a collision occurs. Most importantly, an ongoing system of surveillance and recording of injuries associated with ice hockey is important to identify variables associated with the injuries. In this manner, appropriate steps can be taken to prevent and control injuries in this popular sport. CONCLUSION This study verified previous research and anecdotal comments regarding the significant incidence of injuries to the shoulder girdle in ice hockey. Deterrents to illegal activity and improved equipment and coaching were identified as means of reducing the incidence of these injuries. At- tempts to diminish the impact forces, especially as they occur in the collisions with the boards surrounding the playing surface is a facet of injury prevention that warrants further study. Finally, ongoing surveillance and recording of injuries is encouraged so that trends related to the number, severity, and cause of injuries can be identified and appropriate steps taken to improve the safety of ice hockey. REFERENCES 1. Amateur Hockey Association of the United States, Colorado Springs, Colorado (personal communication) 2. Daffner RH: Injuries in amateur ice hockey: a two year analysis. J Fam Pract 4: Gerberich SG, Finke RC, Madden M, Priest JD, Aamoth G, Murray K: An epidemiological study of high school hockey injuries. Childs New Syst , Gerberich SG: Analyses of high school football injuries and concomitant health care provision. Doctoral Thesis, Two Volumes, University of Minnesota; Minneapolis, Minnesota Hovelius L: Shoulder dislocation in Swedish ice hockey players. Am J Sports Med 6: , Hoyt WA: Etiology of shoulder injuries in athletes. J Bone Joint Surg (Am) 49: , Hull CH, Nie NH: Statistical Package for the Social Sciences Update 7-9. New York: McGraw-Hill Book Co, National Federation of State High School Associations, Official High School Ice Hockey Rules, Nie NH. Hull CH, Jenkins JG, Steinbrenner K, Bent D: Statistical Package for the Social Sciences, Ed 2. New York: McGraw-Hill Book Co, Norfray JF, Tremaine MJ, Groves HC, Bachman DC: The clavicle in hockey. Am J Sports Med 6: , Reilly MF: The nature and causes of hockey injuries: a five year study. Athl Train J , Robertson LS: Injuries: Causes, Control Strategies, and Public Policy. Lexington, MA: Lexington Books, Inc, Sutherland GW: Fire on ice. Am J Sports Med 4: , United States Consumer Product Safety Commission: NElSS Data Highlights. Washington, DC 6(4), 1982

Randall Dick, MS, FACSM*; William A. Romani, PhD, PT, MHA, ATC ; Julie Agel, MA, ATC ; Jim G. Case, ATC ; Stephen W. Marshall, PhD

Randall Dick, MS, FACSM*; William A. Romani, PhD, PT, MHA, ATC ; Julie Agel, MA, ATC ; Jim G. Case, ATC ; Stephen W. Marshall, PhD Journal of Athletic Training 2007;42(2):255 261 by the National Athletic Trainers Association, Inc www.journalofathletictraining.org Descriptive Epidemiology of Collegiate Men s Lacrosse Injuries: National